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APPLICATION ...,N� SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA .95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby Slade to San Joaquin County for a permit to construct and/or install the Work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San ` Joaquin County Public Health Services. Job Address 94 7 EaJ City 1FY�F TQ,d.l Lot Size/Acreage . 9cif OwnerA 's Name ri�ddress o �,�LK.. ,i�G E✓ Phone Contractor WoPl s_LA) a-1itt l)A. Address PD.I?aj,-237 License No.92266 Phone TYPE OF WELL/PUMP. NEW WELL ❑ WELL,REPLACEMENT F1 DESTRUCTION ❑ out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK f e)a SEWER LINES 1 Q DISPOSAL FLD. 15 0 PROP. LINE 5 FOUNDATION t�O AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial . ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private L1 Gravel Pack ❑ Tracy Type of Casing_ Specifications P I'I Public l.I Other P Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by P 5ub Repair Work Done � Type of Pump H.P. I __ ...�..___ State Work Done_ Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth , TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I lNo septic system permitted if public sewer is available within 200 feet I Installation will server Residence_ Commercial_--_ Other ' Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number { SUMPS LI Distance to nearest: Well foundation Property Line DISPOSAL PONDS ❑ r I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting sighature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The appficanl st c H r/II r aired ins tions, Complete drawing on reverse side. C Signed XIV C Title: C `2- Date: FOR DEPARTMENT USE ONLY t 1 Application Accepted by +�- Date 6- y `� 9-�>: Area Pit or Grout Inspection Date Final Inspection by `+ Date �Y Additional Comments: 1 Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 ih _ INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. t EM 13-24(REV.r1w5) O Li g 131q71 k r